Asbestos Management Plan

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1 Asbestos Management Plan This procedural document was previously incorporated within the Asbestos Management Policy and Procedures CORP/HSFS 10 v.3 Did you print this document yourself? The Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. If, for exceptional reasons, you need to print a policy off, it is only valid for 24 hours. Author/reviewer: (this version) Date written/revised: 14 October 2014 Approved by: Date of approval: 28 January 2015 Date issued: 5 March 2015 Next review date: January 2016 Target audience: Mr Howard Timms Assistant Director of Estates and Facilities (Governance) and Mr Sean Tyler Project Officer Policy Approval and Compliance Group All Staff, Trust Wide Page 1 of 46

2 Amendment Form Please record brief details of the changes made alongside the next version number. If the procedural document has been reviewed without change, this information will still need to be recorded although the version number will remain the same. Version Date Issued Brief Summary of Changes Author Version 4 (B) 5 March 2015 Updated and split into two separated documents e.g. Asbestos Management Plan CORP/HSFS 10 (B) and Asbestos Policy CORP/HSFS 10 (A). Update in line with Control of Asbestos Regulations (CAR) (2012) Update in line with Approved Code of Practice (ACOP) L143 and guidance H Timms/S Tyler Version 3 17 October 2013 Updated in line with Control of asbestos regulations New style format included. David Scott Version 2 March 2010 Updated to reflect introduction of HSG 264 Asbestos The Survey Guide Updated to reflect introduction of The Control of Asbestos Regulations 2006 David Scott Version 1 November 2006 Reviewed and re-issued without change David Scott Page 2 of 46

3 Contents Section 1 Important Information 4 2 Introduction 4 3 Purpose 6 4 Roles and Responsibilities 7 5 Strategy for Compliance 12 6 Asbestos Records and Dissemination 14 7 Ongoing Assessment of Asbestos 17 8 Training and Induction 18 9 Safe Systems of Work Monitor and Review Plan for Compliance Action Plan Emergency Procedures Definitions Equality Impact Assessment Associated Trust Procedural Documents References 36 Appendix 1 Survey Type Specification 37 Appendix 2 Assessment Algorithms 39 Appendix 3 Safe Systems of Working Every Day and Maintenance Works 42 Appendix 4 Safe Systems of Working Third Party Contracted Works 43 Appendix 5 Safe Systems of Working Project/Capital Works 44 Appendix 6 Safe Systems of Working IT/Security Works 45 Appendix 7 Equality Impact Assessment Form 46 Page No. Page 3 of 46

4 1. IMPORTANT INFORMATION This Asbestos Management Plan is a document with legal status A copy of the Asbestos Management Plan can be found on the MICAD IPR database If you need help understanding the requirements of this document contact: Asbestos Coordinator: Sean Tyler Number: Ext: In the absence of the above: Howard Timms Number: Ext: INTRODUCTION This Asbestos Management Plan has been designed with the sole purpose of managing the risk from Asbestos Containing Materials (ACMs) identified on throughout the Trust so that as far as reasonably practicable no one can come to any harm from ACMs on the premises. It is an integral part of the Trust s strategy for compliance of all current Health and Safety legislation regarding asbestos. 2.1 Principles of Asbestos Management The main principles of asbestos management are to Assess, Record, Inform and Monitor: Page 4 of 46

5 ASSESS: Asbestos in premises does not necessarily create an unacceptable risk. Asbestos is the hazard; the risk can only be defined when this hazard is assessed within the environment in which it is found. This assessment must take into account the activities carried out near or on the asbestos for the assessment to be able to present viable recommendations. It may take the form of a desktop study, a full asbestos survey, or a combination of the two. RECORD: All assessments and the location and condition of any known or presumed asbestos containing materials must be recorded, updated and regularly reviewed. Similarly, any changes to the condition or location of any known or suspected ACMs, any training, any controlled removal works, re-inspection, etc., must all be recorded. It is imperative that all asbestos documents are kept up to date, are coherent and are accessible. INFORM: All asbestos records gathered must be made available to all relevant people at a suitable time. All staff, contracted workers, regular building users and maintenance staff, etc. may require access to asbestos records held for the site and so they must be made available to anyone who may require them. Additionally, a system of training, seminars, question and answer sessions, as well as site inductions should be adopted where appropriate to ensure that everyone is kept informed about asbestos and that the information they have access to be relevant, accurate and understandable. MONITOR: All asbestos records, procedures, training and safe systems of works must be regularly monitored and reviewed; this is an Approved Code of Practice (ACOP) requirement. The purpose of this on-going monitoring is to ensure that the aims of the asbestos management strategy are being met, that all systems are efficient and workable and that no one is being exposed to asbestos. 2.2 Asbestos Regulations There are many health and safety regulations that either directly or indirectly places a duty on the employer with regards to asbestos. The key facts of these regulations have been set out below: The Health & Safety at Work etc. Act 1974 (HSW): requires employers to conduct their work in such a way that their employees will not be exposed to health and safety risks, and to provide information to other people about their workplace which might affect their health and safety. Section 3 of the HSW Act contains general duties on employers and the self-employed in respect of people other than their own employees. Section 4 contains general duties for anyone who has control, to any extent, over a workplace; The Management of Health & Safety at Work Regulations 1999: (the Management Regulations) requires employers and self-employed people to make an assessment of the risks to the health and safety of themselves, employees and people not in their employment, arising out of or in connection with the conduct of their business and to make appropriate arrangements for protecting those people s health and safety. Any assessment made for the purposes of the Asbestos Regulations will not need to be repeated for the Management Regulations; The Workplace (Health, Safety and Welfare) Regulations 1992: requires employers to maintain workplace buildings so as to protect occupants and workers; Page 5 of 46

6 The Construction (Design & Management) Regulations 2007: require the client to pass on information about the state or condition of any premises (including the presence of hazardous materials such as asbestos) to the CDM Coordinator before any work begins and to ensure that the health and safety file is available for inspection by any person who needs the information. The Defective Premises Act 1972 in England and Wales or the Civic Government (Scotland) Act 1982 in Scotland: places duties on landlords to take reasonable care to see that tenants and other people are safe from personal injury or disease caused by a defect in the state of the premises. Any premises in such a state as to be prejudicial to health constitute a statutory nuisance under section 79 of the Environmental Protection Act An abatement notice can be served by the local authorities on the owner or occupier of premises requiring prevention or restriction of the nuisance; The Control of Asbestos Regulations 2012: requires employers to prevent the exposure of their employees to asbestos, or where this is not practicable, to reduce the exposure to the lowest possible level. Regulation 4 specifically requires duty holders to: a) Take reasonable steps to find materials in premises likely to contain asbestos and to check their condition; b) Presume that materials contain asbestos unless there is strong evidence to suppose that they do not; c) Make a written record of the location and condition of asbestos and presumed asbestoscontaining materials (ACMs) and keep the record up to date; d) Assess the risk of the likelihood of anyone being exposed to these materials; and e) Prepare a plan to manage that risk and put it into effect to ensure that: I. Any material known or presumed to contain asbestos is kept in a good state of repair; II. Any material that contains or is presumed to contain asbestos is, because of the risks associated with its location or condition, repaired or if necessary removed; and III. Information on the location and condition of the material is given to anyone potentially at risk. 3. PURPOSE Doncaster and Bassetlaw Hospitals NHS Foundation Trust recognise their duties under the Health and Safety at Work Act 1974, the Control of Asbestos Regulations 2012 and all associated Approved Codes of Practices and is committed to the effective management of asbestos. Doncaster and Bassetlaw Hospitals NHS Foundation Trust recognise their responsibilities to contractors and others involved in building and maintenance projects established through the Construction (Design and Management) Regulations 2007 and its duties as the Duty Holder of Trust owned buildings as defined by Regulation 4 of the Control of Asbestos Regulations Page 6 of 46

7 This Asbestos Management Plan sets out the strategy for compliance of all relevant Health and Safety legislation regarding asbestos throughout the Trust. This document details what steps will be undertaken to ensure that the risk from known or suspected Asbestos Containing Materials (ACMs) identified is adequately managed, so that as far as reasonably practicable no one can come to any harm from asbestos. It also details the responsibilities of Doncaster and Bassetlaw Hospitals NHS Foundation Trust, its employees, contractors and regular building users. All procedures outlined are mandatory for all parties involved. This document and the procedures outlined require the cooperation of all employees, all staff, building users and contractors who also have responsibilities to ensure a safe and healthy working environment is maintained at all times. This Asbestos Management Plan has been prepared especially for Doncaster and Bassetlaw Hospitals NHS Foundation Trust who throughout this document will be referred to as the Trust. It is a working document and should be regularly updated and amended to ensure it remains valid and as accurate as possible. 4. ROLES AND RESPONSIBILITIES 4.1 Asbestos Coordinator The Asbestos Coordinator is responsible for the day-to-day management of asbestos throughout the Trust. All responsibilities can be delegated, unless otherwise stated, but it should remain the responsibility of the designated person to ensure they are completed satisfactorily. Training requirements: Asbestos awareness, asbestos management and BOHS P405 (Managing asbestos in buildings) On-going training requirements: Annual refresher training Roles & Responsibilities: 1. Oversee asbestos management provision across Doncaster and Bassetlaw Hospitals NHS Foundation Trust. 2. Inform all relevant parties of the asbestos management system and their responsibilities. 3. Oversee the implementation of all procedures and safe systems of work regarding asbestos throughout the Trust. 4. Review agreed roles and nominate as appropriate. Page 7 of 46

8 5. Receive training on ACMs. 6. Ensure re-inspection surveys are undertaken at least annually. 7. Review the Asbestos Management Plan annually (minimum). CORP/ HSFS 10 (B) v.4 8. Ensure the asbestos records (MICAD) are updated following any asbestos works. 9. Ensure an assessment of the hazards and risks from asbestos containing materials is undertaken and recommended appropriate control measures defined. 10. Keep staff and managers informed about asbestos hazards and control measures that are relevant to their work, department and staff. 11. Provide third party contractors commissioned with relevant asbestos information as part of the signing in procedure. 12. Commission and oversee asbestos survey and remedial works. 13. Ensure a Refurbishment & Demolition survey is undertaken ahead of refurbishment and demolition works. 14. Implement appropriate procedures to ensure appropriate management of asbestos remedial works and/or further survey etc. where day to day maintenance activities are affected by the presence of asbestos i.e. task-driven remedial works. 15. Identify persons requiring specific information and instruction in asbestos work and coordinate appropriate training to enable persons to fulfil their responsibilities with regards to asbestos management. 16. Ensure all records are maintained in accordance with the regulatory requirements and codes of practice for asbestos work. 17. Ensure all work carried out on asbestos containing materials complies with current regulations and best practice. 18. Ensure that a suitable assessment is undertaken to determine whether planned works will affect or be affected by asbestos. 19. Ascertain that approved contractors have undertaken asbestos awareness training. 20. Act as the main point of contact for all questions and queries relating to asbestos. 4.2 Capital Project Manager/Estates Manger Training requirements: Asbestos awareness and asbestos management On-going training requirements: Annual refresher training Roles & Responsibilities: 1. Ensure a Refurbishment & Demolition survey is undertaken ahead of refurbishment and demolition works. 2. Coordinate asbestos remediation works in line with the asbestos removal procedure documented in this Asbestos Management Plan. Page 8 of 46

9 3. Ensure the asbestos records (MICAD) are updated following any asbestos works (surveys and remedial works). 4. Act as the main point of contact for any contracted works commissioned and ensure that they are provided with all asbestos information. 5. Ensure works are undertaken with due care and attention following asbestos safe working practices. 6. Ensure satisfied with the asbestos records held, how to interrogate and understand the information held within them. 7. Inform the Asbestos Coordinator if they find any damaged asbestos or if they know that the condition of any ACM has changed in anyway. 8. Fully comply with the Asbestos Coordinator in order to maintain compliance with asbestos legislation and achieve the goal of effective asbestos management. 9. Direct any questions or queries regarding asbestos to the Asbestos Coordinator. 4.3 Team Leader Training requirements: Asbestos awareness, asbestos management and non-licensed asbestos training On-going training requirements: Annual refresher training Roles & Responsibilities: 1. Undertake asbestos training with annual refresher training thereafter. 2. Act as the main point of contact for any contracted works commissioned and ensure that they are provided with all asbestos information. 3. Ensure that a suitable assessment is undertaken to determine whether planned works will affect or be affected by asbestos prior to commencing works. 4. Oversee non-licensed asbestos works undertaken by the maintenance team. 5. Ensure the asbestos records (MICAD) are updated following any asbestos works (surveys and remedial works). 6. Undertake works with due care and attention following asbestos safe working procedures. 7. Ensure satisfied with the asbestos records held, how to interrogate and understand the information held within them. 8. Inform the Asbestos Coordinator if they find any damaged asbestos or if they know that the condition of any ACM has changed in anyway. 9. Fully comply with the Asbestos Coordinator in order to maintain compliance with asbestos legislation and achieve the goal of effective asbestos management. 10. Direct any questions or queries regarding asbestos to the Asbestos Coordinator. Page 9 of 46

10 4.4 Maintenance Team Training requirements: Asbestos awareness. Selected individuals to have non-licensed asbestos training On-going training requirements: Annual refresher training Roles & Responsibilities: 1. Undertake asbestos training with annual refresher training thereafter. 2. Ensure that a suitable assessment is undertaken to determine whether planned works will affect or be affected by asbestos prior to commencing works. 3. Undertake works with due care and attention following asbestos safe working procedures. 4. Ensure satisfied with the asbestos records held, how to interrogate and understand the information held within them. 5. Inform the Asbestos Coordinator if they find any damaged asbestos or if they know that the condition of any ACM has changed in anyway. 6. Fully comply with the Asbestos Coordinator in order to maintain compliance with asbestos legislation and achieve the goal of effective asbestos management. 7. Direct any questions or queries regarding asbestos to the Asbestos Coordinator. 4.5 IT/Security/Telecoms Training requirements: Asbestos awareness and asbestos management On-going training requirements: Annual refresher training Roles & Responsibilities: 1. Liaise with the Estates Department prior to any planned project works, cable laying or works which have the potential to disturb asbestos or access previously inaccessible areas. 2. Act as the main point of contact for any contracted works commissioned and ensure that they are provided with all asbestos information. 3. Ensure works are undertaken with due care and attention following asbestos safe working practices. 4. Ensure satisfied with the asbestos records held, how to interrogate and understand the information held within them. 5. Inform the Asbestos Coordinator if they find any damaged asbestos or if they know that the condition of any ACM has changed in anyway. 6. Fully comply with the Asbestos Coordinator in order to maintain compliance with asbestos legislation and achieve the goal of effective asbestos management. 7. Direct any questions or queries regarding asbestos to the Asbestos Coordinator. Page 10 of 46

11 4.6 Measured Term Contractor Training requirements: Asbestos awareness On-going training requirements: Annual refresher training Roles & Responsibilities: 1. Provide the Trust with verification that all operatives have undertaken asbestos awareness training. 2. Act as the main point of contact for any subcontracted works commissioned and ensure that they are provided with all asbestos information. 3. Ensure that a suitable assessment is undertaken to determine whether planned works will affect or be affected by asbestos prior to commencing works. 4. Ensure works are undertaken with due care and attention following asbestos safe working practices. 5. Ensure satisfied with the asbestos records held, how to interrogate and understand the information held within them. 6. Stop works IMMEDIATELY and inform the Asbestos Coordinator if they find any previously unidentified asbestos, damaged asbestos or if they know that the condition of any ACM has changed in anyway. 7. Fully comply with the Asbestos Coordinator in order to maintain compliance with asbestos legislation and achieve the goal of effective asbestos management. 8. Direct any questions or queries regarding asbestos to the Asbestos Coordinator. 4.7 General Contractor Training requirements: Asbestos awareness On-going training requirements: Annual refresher training Roles & Responsibilities: 1. Provide the Trust with verification that all operatives have undertaken asbestos awareness training. 2. Ensure works are undertaken with due care and attention following asbestos safe working practices. 3. Ensure satisfied with asbestos safe working procedures within the Trust and operate within these procedures. Page 11 of 46

12 4. Stop works IMMEDIATELY and inform the Asbestos Coordinator if they find any previously unidentified asbestos, damaged asbestos or if they know that the condition of any ACM has changed in anyway. 5. Fully comply with the Asbestos Coordinator in order to maintain compliance with asbestos legislation and achieve the goal of effective asbestos management. 6. Direct any questions or queries regarding asbestos to the Asbestos Coordinator. Roles and Responsibilities training requirements summary Role Asbestos Awareness Asbestos Management Non-licensed asbestos work (selected individuals) BOHS P405 Annual Refresher Asbestos Coordinator Project Managers Maintenance Team Leader Maintenance Team IT/Security/Telecoms Measured Term Contractor General Contractor See Section 8: Induction & Training 5. STRATEGY FOR COMPLIANCE This Asbestos Management Plan outlines how the Trust is managing the risk from known or suspected asbestos throughout the Doncaster and Bassetlaw Hospitals NHS Foundation Trust site. 5.1 Current Provision Historically, a number of asbestos surveys and remedial works have been undertaken throughout the Trust. Copies of these asbestos records can be accessed through the MICAD database or through the Estates Department. Page 12 of 46

13 The MICAD asbestos portal will eventually become the primary means in which asbestos information is shared throughout the Trust. More recently, a re-inspection programme has been undertaken throughout Bassetlaw and Mexborough Montagu sites which included attempted access of previously inaccessible areas. The results of these surveys have been uploaded to the MICAD asbestos database. Asbestos awareness and management training courses have recently been undertaken. Further courses are to be undertaken in the new future to capture any personnel who missed the initial training courses. 5.2 Future Provision Within the next six months to one year the Trust aims to have the following aspects of its provision for asbestos management completed; 1. Undertake a programme of management surveys in areas not previously accessed at Doncaster Royal Infirmary. 2. Review existing asbestos information held on the MICAD database for inconsistencies (e.g. inconsistencies known to be present for areas where no access has been gained). 3. Identify personnel who have not undertaken asbestos training and provide appropriate training. 4. Non-licensed asbestos training to be undertaken by selected members of the maintenance team. 5. Devise an action plan for removal or encapsulation of high risk asbestos materials identified throughout the Trust. 6. Further develop the site induction procedure. 7. Implement a safe system of work procedure for IT, Security and Telecoms works and ensure they are fully informed of the requirements of the asbestos management system put in place. 8. Ensure the maintenance team are reminded of the requirement to assess planned works against the asbestos records. 9. Further development of the works dockets to implement a warning note to remind operatives of the need to consult the asbestos register. 10. Provide access to the MICAD asbestos portal to all those who undertake or manage woks which have the potential to disturb known asbestos or access previously inaccessible areas. 11. Provide adequate instruction and training to all users of the MICAD asbestos portal. Page 13 of 46

14 12. Request verification from Trust approved contractors that operatives have received asbestos awareness training and that the training is in date. 13. Request verification from term maintenance contractors that they have access to the asbestos records and will assess their planned works against the asbestos register prior to commencing works. 14. Inform all relevant parties of their responsibilities (and provide adequate training where appropriate) with regards to asbestos management provision. Personnel to be made aware of the asbestos records and how to assess planned works accurately taking into account areas of no access and areas outside the scope of survey information available. 15. Undertake an annual review of the Asbestos Management Plan. 6. ASBESTOS RECORDS AND DISSEMINATION 6.1 Current Asbestos Records The following summarises what information is held and how it is disseminated: ASBESTOS MANAGEMENT PLAN: The Control of Asbestos Regulations 2012 requires all duty holders as part of their on-going asbestos management to have a written Asbestos Management Plan (this document). This document details what steps will be taken to effectively manage all items of asbestos; it is specifically written for Doncaster and Bassetlaw Hospitals NHS Foundation Trust and cannot be transferred. It also details all assessments made of ACMs (asbestos-containing materials) and provides recommendations, priorities and deadlines for action. The Asbestos Management Plan is held electronically on the MICAD database. Access can be gained through the Estates Office. ASBESTOS REGISTERS: Information regarding the location and condition of asbestos throughout the Trust has been recorded in the asbestos surveys undertaken. This information has been uploaded to the MICAD database. Any persons accessing the asbestos registers should be aware of limitations, scope and any areas not accessed during any survey works. If they are unsure as to how to interpret the data within the reports then further information should be sought from the Asbestos Coordinator before commencing works. This Asbestos Management Plan should be read in conjunction with the asbestos registers held. ASBESTOS POLICY: The Trust asbestos policy sets out the Trusts statement of intent with regards to compliance with the Control of Asbestos Regulations This Asbestos Management Plan should be read alongside the asbestos policy. Page 14 of 46

15 MICAD DATABASE: As asbestos information is acquired it is recorded onto the MICAD database. This process is already up and running within the Trust and is updated each time new asbestos information is available either through surveys, bulk sampling or asbestos remediation programmes. The MICAD database is the primary way in which asbestos information is shared within the Trust. The Asbestos Coordinator is responsible for overseeing the MICAD database. All persons who commission asbestos surveys, bulk samples or remediation works are responsible for ensuring that the MICAD database is updated following the completion of works in line with this Asbestos Management Plan. The MICAD database can be accessed through the Estates Department. ASBESTOS REMEDIATION: All details of asbestos removal or remedial works undertaken to date have been recorded. Remediation records are held electronically on the MICAD database. The Asbestos Coordinator will ensure that all persons who commission any future remediation works are aware of the requirement to ensure that the MICAD database is updated. REINSPECTIONS: Regulation 4(9) of the Control of Asbestos Regulations 2012 states that: (9) The measures to be specified in the plan for managing the risk shall include adequate measures for (a) monitoring the condition of any asbestos or any substance containing or suspected of containing asbestos.. Any ACMs identified or suspected are re-inspected at least annually to check that it has not changed condition, deteriorated or been damaged in any way. Re-inspections are undertaken in accordance with the Approved Code of Practice, L143 second edition (Managing and working with asbestos). TRAINING RECORDS: The maintenance team and all those who plan and manage works which may affect or be affected by asbestos will be given an appropriate level of training and help to understand their responsibilities and any information regarding asbestos. All training will be an on-going process and will be organised by the Asbestos Coordinator. Training records are collated as training is undertaken and will detail the training given to each employee. Any training certificates received are held centrally as a full record of who has received what training and when. These records are treated as confidential to each member of staff and are kept in a controlled location. Each employee will, however, have access to their own records upon request. Page 15 of 46

16 Refresher training will be undertaken annually. Any new starters or others identified as benefitting from training and / or additional training will be provided with suitable training at the earliest available opportunity. 6.2 Further Asbestos Records The following summarises what information should be collated and maintained: RECORDS OF EXPOSURE/INCIDENTS: These records will be collated if necessary to detail the exact nature and known extent of any exposure to asbestos that has occurred in any part of the Trust or to a Trust employee: contractors, including asbestos removal contractors will be expected to control the records of their own staff unless previously arranged. Whilst every step has been taken to ensure exposure to asbestos does not occur, it is vital good record keeping is maintained. These records will be treated as confidential to each member of staff and be kept in a controlled location by the Asbestos Coordinator. Each employee will have access to their own records upon request. 6.3 Updating Information It is imperative that all asbestos records are regularly updated with any new information that becomes available. Asbestos records will be updated covering the following: Action Timescale Responsible Party Remedial/removal works Upon completion of works Person commissioning the works/ Asbestos Coordinator Re-inspections, bulk sampling, further surveys works (including refurbishment and demolition surveys) Training Site inductions Accidental disturbance of known or suspected ACMs Upon completion of works Upon completion of training Upon completion of site induction Upon accidental disturbance of asbestos Person commissioning the works/ Asbestos Coordinator Asbestos Coordinator Person commissioning the works/ Asbestos Coordinator Asbestos Coordinator Page 16 of 46

17 Action Timescale Responsible Party Task assessments Upon completion of task assessments All persons undertaking works/ Asbestos Coordinator Any changes made to the contact details for the Asbestos Coordinator and/or emergency contacts Any changes to the organisational structure of The Trust which may affect asbestos management facilities Any new procedures adopted If/when contact details are amended If/when organisational changes are made If/when new procedures are adopted Asbestos Coordinator Asbestos Coordinator Asbestos Coordinator 7. ONGOING ASSESSMENT OF ASBESTOS On-Going Assessment On-going assessment of known or suspected ACMs will take the form of periodic re-inspection surveys as in accordance with the Control of Asbestos Regulations It is imperative that both known and presumed asbestos containing materials are effectively monitored and that all asbestos information is as up to date and accurate as possible. Similarly, any management procedures, permit-to-work systems, etc., will be audited and regularly assessed to ensure that they are achieving the goal of effective asbestos management. If any procedures are proved to be inadequate or any accidental or unknown disturbance of asbestos materials has occurred then the necessary action can be taken. RE-INSPECTION: All items that have been positively identified will undergo regular, on-going reinspections at 12 monthly intervals (minimum) from the date of the last inspection/survey. The purpose of undertaking the re-inspection is to ensure that Material and Priority Assessments are still current. i.e. that the material has not deteriorated in any way and that the use of the building has not changed. Any change to either criterion will result in the overall Risk Assessment being invalid and therefore a new assessment will be required. This will in turn be recorded. Re-inspections are a requirement of ACOP L143 second edition, (Managing and working with asbestos). The Asbestos Coordinator is responsible for ensuring that re-inspections are undertaken annually and that the MICAD database is updated following completion of the works. Page 17 of 46

18 MONITOR AND REVIEW: This Asbestos Management Plan will be regularly reviewed and revised annually by the Asbestos Coordinator to ensure that all information is correct and that the plan achieves its objectives. More information regarding how the Asbestos Management Plan will be monitored and reviewed is given in Section 8. See Section 10: How to Monitor & Review rreviewreview this Plan 8. TRAINING AND INDUCTION Different training and induction will be provided for different building users; the purpose being to provide all relevant personnel with the skills and knowledge necessary to understand the hazards and risks involved when working in or near an area where asbestos has been identified. Training will be provided for all relevant The Trust employees. Site inductions will be undertaken for all third party contractors. This training/induction will be provided prior to any persons commencing work to enable persons to work safely. Within the Trust four main user groups have been identified as requiring training: 1. MAINTENANCE TEAM: Any staff directly employed by the Trust whose work could foreseeably expose them to asbestos will be provided with asbestos awareness training. 2. THIRD PARTY CONTRACTORS: Any contractors whose work may affect or be affected by asbestos present will be provided with a site induction. 3. THOSE WHO PLAN AND MANAGE WORKS: Anyone who is involved in planning or supervising works which may affect or be affected by ACMs will be provided with asbestos management training. 4. NON-LICENSABLE ASBESTOS WORK: Anyone whose work will knowingly disturb ACMs or access above ceiling voids should be provided with non-licensable asbestos training in addition to the asbestos awareness training requirement identified above. P405: Those responsible for managing asbestos within the Trust (the Asbestos Coordinator) should undertake the BOHS proficiency module, P405 Managing asbestos in buildings. It is not envisaged that any training or site induction is required for administration or general staff within The Trust or for any general visitors to the site where their works will not be affected by any asbestos present. Page 18 of 46

19 8.1 Maintenance Team As in accordance with the ACOP L143 second edition, Managing and working with asbestos, employees whose work could foreseeably expose them to asbestos will be provided with compulsory asbestos awareness training. This includes all those who carry out routine maintenance, or regularly access voids or risers, or regularly disturb the fabric of the building. Training will cover the following topics; 1. The properties of asbestos and its effects on health, including the increased risk of lung cancer for asbestos workers who smoke; 2. The types, uses and likely occurrence of asbestos and ACMs in buildings and plant; 3. The general procedures to be followed to deal with an emergency; and 4. How to avoid the risks from asbestos. Asbestos awareness refresher training was undertaken in June Any persons identified as not being incorporated onto the initial training course will be provided with asbestos awareness training at the next available opportunity. The Asbestos Coordinator is responsible for organising training and for ensuring that annual refresher training is undertaken. 8.2 Third Party Contractors The Trust recognises its responsibilities to contractors and will ensure that adequate information, instruction and training is provided to any contractors on its premises in the form of a site induction. Contractors appointed to work on the Trust premises are expected to have undertaken asbestos awareness training as in accordance with Regulation 10 of CAR Those commissioning third party contracted works are responsible for checking the asbestos records prior to commissioning works and for relaying any relevant asbestos information to contractors as part of the signing in procedures. The information provided during the site induction should cover: 1. A brief summary of the location of any known or suspected ACMs which may affect, or are local to, the planned works. 2. The types of activities which are prohibited, areas which are controlled access, etc. Page 19 of 46

20 3. What to do should they suspect ACMs have been accidentally disturbed along with a contact number. In addition, it is also important to emphasise that any damage to an ACM no matter how minor - MUST be reported to their site contact who is responsible for informing the Asbestos Coordinator as soon as possible. Persons who have direct involvement in emergency procedures, such as the Fire Brigade, etc, will also be included here, but they will be best served by a copy of the Asbestos Register being made available to them, and liaising with them as to what further information they need. 8.3 Those Who Plan Work and Manage Work All those who order, plan or supervise works should be provided with asbestos management training. This includes representatives from IT, security and telecoms. Training should cover; 1. A brief introduction explaining what asbestos is, and the hazards associated with it, etc. 2. A brief summary of the information held by The Trust and how to gain access to it. 3. A brief summary of products likely to contain asbestos and where they are likely to be found. 4. The types of activities which are prohibited, areas which are controlled access, etc. 5. The limitations of a survey and certificates of reoccupation. 6. Air monitoring and selecting an analyst. 7. Asbestos surveys and selecting a surveyor. 8. The main legislative requirements, in particular Regulation 4, of the Control of Asbestos Regulations All training provided will be recorded and a certificate of attendance issued. 8.4 Non-Licensable Asbestos Work Non licensable asbestos training will however be required by anyone wishing to access contaminated areas and / or undertake non licensable asbestos works. Training should cover the following topics in appropriate detail: 1. The operations which could result in asbestos exposure and the importance of preventative controls to minimise exposure; Page 20 of 46

21 2. How to make suitable and sufficient assessments of the risk of exposure to asbestos; 3. The control limit, and the purpose of air monitoring; 4. Safe working practices, control measures, and protective equipment including an explanation of how the correct use of control measures, protective equipment and work methods can reduce the risks from asbestos, limit exposure to workers and limit the spread of asbestos fibres outside of the work area; 5. The maintenance of control measures, including where relevant the maintenance of enclosures; 6. Procedures for recording, reporting and correcting defects; 7. The appropriate purpose, choice and correct selection from a range of suitable RPE, including any limitations; 8. The correct use, and where relevant, cleaning, maintenance and safe storage of RPE and PPE, in accordance with the manufacturer s instructions and information; 9. The importance of achieving and maintaining a good face seal between face and RPE, the relevance of fit tests, and the importance of being clean-shaven. 10. Hygiene requirements; 11. Decontamination procedures; 12. Waste handling procedures; 13. Emergency procedures; 14. Which work requires an HSE licence; 15. An introduction to the relevant Regulations, Approved Codes of Practice and guidance that apply to asbestos work and other Regulations that deal with the carriage and disposal of asbestos; 16. Other work hazards including working at height, electrical, slips, trips and falls. 8.5 P405 In order to ensure that the Asbestos Coordinator has sufficient asbestos knowledge and training to understand the requirements of CAR 2012 and their responsibilities it is recommended that the Trust consider the BOHS (British Occupational Hygiene Society) proficiency certificate in the Management of Asbestos in Buildings (P405) for the Asbestos Coordinator. Page 21 of 46

22 The P405 course is designed to provide delegates with the practical knowledge and the skills to be able to manage asbestos in buildings and to provide a basic knowledge of asbestos removal procedures. The course syllabus covers: 1. Legislation a. Health & Safety at Work Etc. Act 1974 b. Asbestos Regulations c. Approved Codes of Practice d. Health Effects of Asbestos 2. Management of Asbestos in Buildings a. Types and Uses of Asbestos in Buildings 3. Asbestos Remediation a. Preparation b. Enclosures c. Remediation Measures d. Removal Procedures e. Waste Removal 4. Role of the Laboratory/Analyst a. Role of Analyst b. Air Monitoring and Other Techniques c. Four Stage Clearance Procedure and Testing of Enclosures 5. Practical Work a. Pre-start Inspections b. Role Playing The above will ensure that the Trust have an appropriately trained, competent and knowledgeable person to act as an onsite representative for the Trust enabling them to deal with queries and oversee the asbestos management provisions put in place. 8.6 Future Training The Trust will proactively seek to identify any persons who need to receive asbestos training in the future; for example the IT department or any other people where it is deemed that asbestos training would be beneficial to them. They will be incorporated into the appropriate level of asbestos training as soon as can be accommodated. This may include anyone who has particularly requested more information regarding asbestos; or anyone else deemed in a position that will benefit from asbestos training. It is possible that these sessions can be open-invite to a certain extent, and will be done in a short presentation, and maybe a question and answer session. Page 22 of 46

23 Additionally, asbestos refresher training of an appropriate level will be carried out throughout the Trust to ensure that up to date and accurate asbestos knowledge best compliments the management strategies put in place. 9. SAFE SYSTEMS OF WORK A safe system of work is a procedure or adopted policy which should always be followed to ensure that the relevant precautions are taken and that no-one is exposed to asbestos during the course of their work. Any planned maintenance activities, refurbishment, demolition works or works which may impact upon known or suspected asbestos will not take place until an assessment of the task has been carried out by a competent person. This assessment will be undertaken prior to any works being undertaken and will be documented. In this section six main processes are described; 1. EVERYDAY MAINTENANCE WORKS: A safe systems of work procedure involving Site Services maintenance personnel who work within the site on a day to day basis. 2. THIRD PARTY CONTRACTORS: A safe systems of work procedure for works involving third party contractors who complete work within the site as a one-off for a defined period of time. 3. PROJECT WORKS: A safe systems of work procedure for all project / capital works. 4. IT / TELECOMS / SECURITY WORKS: A safe systems of work procedure for all IT, telecoms and security works. 5. ASBESTOS REMOVAL WORKS: A safe systems of work procedure for all asbestos removal and / or remedial works. 6. UNPLANNED INCIDENTS: A safe systems of work procedure for accidental disturbance of asbestos. 9.1 Every Day and Maintenance Works; Works which are carried out by Maintenance Operatives have been grouped here. All maintenance works are currently logged into the Estates Labour Management System. Works are then passed to the maintenance team leaders who in turn allocate to the maintenance team. It I the responsibility of the operative undertaking the works to assess the planned works against the electronic copy of the asbestos records held on site. In time, the maintenance team will have access to the MICAD asbestos portal. Page 23 of 46

24 The Asbestos Coordinator will look to include a prompt on the works docket issued to remind operatives of the need to check the planned works against the asbestos records prior to commencing works. It is essential that an assessment is undertaken to determine whether planned works are taking place in area where asbestos is known or presumed to be present, in areas of no access etc. If asbestos is found to be present then works should not proceed until the Asbestos Coordinator has been consulted and a safe system of work put in place. For every-day maintenance works, once this task assessment has been carried out and a safe system of work defined, then provided the environment remains the same, it will be valid for all such activities. Some guidance may be needed to assess certain maintenance activities, but essentially every task should be checked to ensure that no-one is accidentally disturbing known or suspected asbestos containing materials whilst carrying out a task. All persons must cooperate with the process of identification, assessment and control of asbestos, and participate in training and induction programmes. Employees should be made aware that areas listed as No Access on any Asbestos Register must be presumed to contain asbestos unless there is strong evidence to the contrary. Procedures for those working near known asbestos, including emergency procedures, should also be clearly communicated. 9.2 Third Party Contracted Works; This group consists of works which are carried out by third party contractors excluding IT/ Telecoms and Security contractors. It is expected that contractors employed to undertake maintenance on behalf of the Trust which may disturb the fabric of the building or known or presumed ACMs have undertaken asbestos awareness training as in accordance with Regulation 10 of CAR The Trust is not responsible for providing third party contractors commissioned with asbestos awareness training, they will however provide them will all relevant asbestos information to the planned works before they attend site and also during the signing in procedure before works commence. Copies of risk assessments and method statements are requested from contractors ahead of their planned works onsite. In return all relevant asbestos information to the planned works is shared with the contractor. All Estates commissioned contractors are required to report to the Estates Department upon arrival where they sign in and are provided with a contractor s badge. The Trust are currently developing and looking into various site induction options and currently no formal site induction is undertaken for contractors. It is the responsibility of the person commissioning the works to assess the planned works against the asbestos records held or to contact the Asbestos Coordinator ahead of planned works to avoid unnecessary expense or delays. It is just as important to inform all concerned if no asbestos is present but that safe systems of work should always be followed. Should any ACMs be discovered during the course of the works Page 24 of 46

25 or if it is suspected that asbestos may have been disturbed then works should be stopped and the Asbestos Coordinator should be notified immediately. It is important to note that whoever commissions the works from third party contractors is responsible for ensuring that they report to the Estates Department upon arrival to sign in. All contractors should be required to provide copies of their policies in relation to the general provisions of the Health and Safety at Work Act 1974, and asbestos management. They should in turn be given access to all relevant Asbestos Records. All persons must cooperate with the process of identification, assessment and control of asbestos and participate in training and induction programmes. Employees and contractors should be made aware that areas listed as No Access on any Asbestos Register must be presumed to contain asbestos unless there is strong evidence to the contrary. Procedures for those working near known asbestos, including emergency procedures, should also be clearly communicated. 9.3 Project Works/Capital Works This group consists of all project driven tasks and any tasks which are not carried out by the Trust s own staff. All project/capital works undertaken within the Trust are procured through the Capital Team. The Project Manager for the works is responsible for the commissioning of additional surveys (including Refurbishment and Demolition surveys ahead of any refurbishment/demolition works) and arranging remedial works ahead of any planned works. The Project Manager is also responsible for ensuring that the MICAD asbestos database is updated following the completion of any works. The Trust will ensure that unless commissioned through a Principal contractor that they engage the services of an analytical company directly. Under no circumstances will the asbestos removal contractor commission the services of the analytical company on behalf of the Trust. For any projects that fall under the CDM Regulations 2007 (Construction, Design & Management) the Trust will ensure that the CDM Co-ordinator is provided with all asbestos information in their possession relating to the project for inclusion in the Health and Safety file as in accordance with Regulation 4(9)(C) of the Control of Asbestos Regulations Contractors will also be informed that should they discover any ACMs during the course of their work, that they must notify the Asbestos Coordinator IMMEDIATELY. All persons must cooperate with the process of identification, assessment and control of asbestos and participate in training and induction programmes. Page 25 of 46

26 Employees and contractors should be made aware that areas listed as No Access on any Asbestos Register must be presumed to contain asbestos unless there is strong evidence to the contrary. Procedures for those working near known asbestos, including emergency procedures, should also be clearly communicated. 9.4 IT/Telecom/Security Works This group consists of all IT, telecoms and security works that have the potential to disturb known or presumed asbestos or access areas previously inaccessible (such as cable laying, making penetrations to ceilings/walls, CCTV installation). Historically, IT and security have both been known to request asbestos information from the Estates Department; however, there is no documented procedure for IT/security related works. Prior to any works that have the potential to disturb the fabric of the building, access previously inaccessible areas (such as ceiling voids) or disturb known or presumed asbestos the Estates Department must be contacted in all instances so that the planned works are checked against all available asbestos records held on MICAD. All IT and security contractors are also expected to report to whoever has commissioned the works upon arrival to site where they are asked to sign in. Contractors will also be informed that should they discover any ACMs during the course of their work, that they must notify the Asbestos Coordinator IMMEDIATELY. All persons must cooperate with the process of identification, assessment and control of asbestos and participate in training and induction programmes. Employees and contractors should be made aware that areas listed as No Access on any Asbestos Register must be presumed to contain asbestos unless there is strong evidence to the contrary. Procedures for those working near known asbestos, including emergency procedures, should also be clearly communicated. This written procedure ensures that the correct steps are undertaken to avoid the disturbance of asbestos during any works. 9.5 Asbestos Removal This group consists of all maintenance and project driven asbestos removal works. Currently the Asbestos Coordinator, Project Managers and Maintenance Team Leaders can commission asbestos remedial/removal works. This procedure is designed to ensure that there is a consistent approach for all asbestos removal works. It should be noted that only Trust approved removal contractors and analytical companies will be employed to undertake asbestos removal and analytical works on any Trust owned or controlled property. Page 26 of 46

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